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Rehabilitation Election BWC-7208 - Ohio

Rehabilitation Election Form. This is a Ohio form and can be used in Employers Workers Comp .
 Fillable pdf Last Modified 1/20/2014
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30 W. Spring St. Columbus, OH 43215-2256 Dear Self-insured applicant: Self-insuring employers may elect to pay rehabilitation costs directly in accordance with Ohio Revised Code (ORC) section 4121.66 as amended by Amended Substitute House Bill (HB) 107. Employers exercising the option will no longer be assessed the portion of the surplus fund assessments for rehabilitation costs, although self-insuring employers will be responsible for any deficit amount in such assessments calculated pursuant to the provisions of ORC section 4123.34 (B) as amended by Amended Substitute HB 107. If your company elects to pay rehabilitation cost directly, the election becomes effective upon approval of self-insurance. If your company elects to pay rehabilitation costs directly, please complete the bottom portion of this letter and return it to the self-insurance department at the address above. This election is irrevocable BWC USE ONLY Applicant number I hereby elect to pay rehabilitation costs directly, in accordance with the provisions of ยง4121.66, as amended by Am. Sub. HB 107. I certify that I am empowered to make this election on behalf of (Company name) Signature Title Date BWC-7208 (Rev. 10/9/1997) SI-8 American LegalNet, Inc. www.FormsWorkFlow.com
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